Nutritional Assessment and Treatment Strategies

Linda Van Horn, Ph.D., R.D.

In 1990, the American Academy of Family Physicians, the American Dietetic Association and the National Council on Aging formed the Nutrition Screening Initiative (NSI). The U.S. Department of Health and Human Services' Report, Healthy People 2000, stated that 2.5-4.9 million elderly suffer from hunger. NSI called for increased nutrition screening by geriatricians and other health care professionals and developed assessment tools. There is increasing evidence that well nourished patients have shorter hospital stays and fewer complications, adding to the potential benefits of aggressive dietary assessment and intervention.

Limitation of Biochemical Assessment

The physical and biochemical assessment of nutritional status is problematic in older adults because the parameters may change significantly only when severe malnutrition is present. For example:

• The half-life of serum albumin is too long for this value to reflect recent changes in nutritional status. Serum albumin is also sensitive to changes in hydration status and may be unreliable.
• The effects of chronic and concurrent illness may also decrease the usefulness of other laboratory indicators such as Total Iron Binding Capacity, Total Lymphocyte Count and cholesterol.
• In this patient population, the primary type of malnutrition is not kwashiorkor, total protein depletion, but marasmus, a combination protein-calorie malnutrition that is characterized by underweight with minimally affected protein stores.
• Changes in fat deposition and skin elasticity with aging may make anthropometrics unreliable.

The goal of nutritional assessment is to prevent malnutrition, identifying risk before the condition is severe. The aim, then, is to identify conditions and behaviors that put patients at risk and to intervene before severe malnutrition ensues. Your medical assessment should include history, physical examination and medication review, to identify potentially treatable illnesses or implicate medications that may interfere with procurement, preparation, eating, swallowing and digestion. Special emphasis should be placed on the evaluation of oral health- to rule out poorly fitting dentures, poor oral hygiene or oral pathology that may cause pain or difficulty in chewing.

Risk Factors of Poor Nutritional Status in Older Americans

The Advisory Panel identified the following characteristics as risk factors:

Inappropriate Food Intake

Quantity, quality, frequency.

Poverty

Limited access to food, lower priority than utility bills, medication expenses, etc.

Social Isolation

Losses of family, friends, independence resulting in loneliness, grief and/or depression can affect appetite or interest in preparing food.

Dependence/Disability

Inability to procure/prepare food.

Acute/Chronic Diseases or Conditions

Can alter food intake or require therapeutic diet. These include cardiovascular processes, diabetes, renal disease, poor oral health, stomatitis and others.

Chronic Medication Use

Adverse drug-nutrient interactions. Table 1 lists commonly prescribed drugs that are associated with reduced dietary intake.

Advanced Age

Chronological age and functional capacity do not necessarily equate; individualize treatment.

Table 1: Drugs Associated with Decreased Dietary Intake (not all-inclusive)

Anorexia

Alcohol

Digitalis

Hydrochlorothiazide

Triamterene

Antineoplastic drugs

Gastric irritation

Iron and potassium

Theophylline

Salicylates and nonsteroidal anti-inflammatory drugs

Antibiotics (erythromycin, tetracycline)

Hypogeusia ( taste sensation)

Allopurinol

Clindamycin

Antihistamines

D-penicillamine

Griseofulvin

Anticholinergic properties (dry mouth, confusion)

Atropine

Phenothiazine tranquilizers

Tricyclic antidepressants

Antihistamines

Indications for Consultation

This handbook includes a pocket card copy of the NSI Level I Nutrition Screen (Reprinted with permission by the Nutrition Screening Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association and the National Council on the Aging, Inc. and funded in part by a grant from Ross Products Division, Abbott Laboratories). Patients assessed to be at risk should be referred to a dietitian who can assess, educate, counsel and monitor changes in diet. The dietitian can also work with the patient and family to find dietary strategies that are culturally relevant and financially feasible. This will enhance compliance with specialized diets and generally improve oral intake.

Common consultation questions:

• special diets, e.g., renal, diabetic, low salt, low fat, weight gain or reduction.
• strategies in seasoning, presentation, portion and frequency designed to make specialized diets more palatable or to generally increase interest in food.
• techniques to increase protein and calorie intake without increasing salt or fat.

Consultation with a social worker is essential when addressing financial or social causes of nutritional risk and to access community resources, i.e., Meals on Wheels, congregate meals and food stamps.

Copyright ©1999. Northwestern University. All Rights Reserved. Edited by the Buehler Center on Aging, McGaw Medical Center. For information regarding content contact: James R. Webster, j-webster@northwestern.edu Published electronically by the Galter Health Sciences Library. For information regarding publication contact: James Shedlock, j-shedlock@northwestern.edu Last Updated: June 9, 1999